Medical surgical nursing for nursing student

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EDO UNIVERSITY IYAMHO
Department of Nursing Science
NSC 301 Medical Surgical Nursing
Instructor: Mr. Ogunlade, Alade Aderinto; email:ogunlade.alade@edouniversity.edu.ng
Lectures: Monday, 10am – 12 pm, LT3, phone: (+234) 8062489290
Office hours: Monday, 8 am to 9:45 am (just before class), Office: Department of Nursing Rm
37
Teaching Assistants: Mr. N.E Chukwuyem
General overview of lecture: This introduces students to surgical patients with emergencies as
well as cares before, during and after operation.
Prerequisites: Students should have knowledge of foundation of professional nursing practice
and theory, anatomy, physiology and biochemistry.
Learning outcomes: At the completion of this course, students are expected to:
i. differentiate among classifications of surgery and types of anaesthesia.
ii. describe the assessment data to collect for a surgical patient.
iii. demonstrate postoperative exercises: diaphragmatic breathing, coughing, incentive
spirometer use, turning, and leg exercises.
iv. design a preoperative teaching plan
v. prepare a patient for surgery.
vi. explain the nurse’s role in the operating room.
vii. describe the rationale for nursing interventions designed to prevent postoperative
complications.
Assignments: We expect to have 5 individual homework assignments throughout the course in
addition to a Mid-Term Test and a Final Exam. Home works are due at the beginning of the class
on the due date. Home works are organized and structured as preparation for the midterm and
final exam, and are meant to be a studying material for both exams. There will also be seminar
presentation.
Grading: We will assign 10% of this class grade to home-works, 10% for seminar presentations,
10% for the mid-term test and 70% for the final exam. The Final exam is comprehensive.
Textbook: The recommended textbooks for this class are as stated:
Title: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing.
Authors: Smeltzer, S.C., Bare, B.G., Hinkle, J.L and Cheever, K.H
Publisher: Wolters Kluwer Health / Lippincott Williams & Wilkins.
ISBN-978-1-60831-080-7
Title: Introductory Medical-Surgical Nursing
Authors: Timby, B.K and Smith, N.E.
Publisher: Wolters Kluwer Health / Lippincott Williams & Wilkins.
ISBN- 978-1-60547-063-4
Main Lecture: Below is a description of the contents.

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Introduction to Perioperative Concepts and Nursing Management
Perioperative nursing care is nursing care given before (preoperative), during (intraoperative),
and after (postoperative) surgery. It takes place in hospitals, surgical centres attached to
hospitals, freestanding surgical centres, or health care providers’ offices. Perioperative nursing is
a fast-paced, changing, and challenging field. It is based on the nurse’s understanding of several
important principles, including:
a) High-quality and patient safety–focused care.
b) Multidisciplinary teamwork.
c) Effective therapeutic communication and collaboration with the patient, the patient’s family,
and the surgical team.
d) Effective and efficient assessment and intervention in all phases of surgery.
e) Advocacy for the patient and the patient’s family.
f) Understanding of cost containment.
Working in a perioperative setting, requires the practice of strict surgical asepsis, thoroughly
documentation of care, and laying emphasis on patient safety in all phases of care. Effective
teaching and discharge planning prevent or minimize complications and ensure quality
outcomes.
Classification of Surgical Procedures
a. According to Seriousness
Major: Involves extensive reconstruction or alteration in body parts; poses great risks to well-
being for example, Coronary artery bypass, colon resection, removal of larynx, and resection of
lung lobe.
Minor: Involves minimal alteration in body parts; often designed to correct deformities; involves
minimal risks compared with major procedures e.g. Cataract extraction, facial plastic surgery,
and tooth extraction.
b. According to Urgency
Elective: It is performed on basis of patient’s choice; is not essential and is not always necessary
for health. Examples are; facial plastic surgery, hernia repair, and breast reconstruction
Urgent: It is Necessary for patient’s health; often prevents additional problems from developing
(e.g., tissue destruction or impaired organ function); not necessarily emergency Excision of
cancerous tumour, removal of gallbladder for stones, vascular repair for obstructed artery (e.g.,
coronary artery bypass)
Emergency: This must be done immediately to save life or preserve function of body part.
Examples are; repair of perforated appendix or traumatic amputation, control of internal
haemorrhage
c. According to Purpose
Diagnostic Surgical exploration: This allows health care providers to confirm diagnosis; often
involves removal of tissue for further diagnostic testing e.g. exploratory laparotomy (incision
into peritoneal cavity to inspect abdominal organs), breast mass biopsy.
Palliative Relieves: It reduces intensity of disease symptoms; does not produce cure. Examples
include Colostomy, debridement of necrotic tissue, resection of nerve roots.

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Reconstructive/restorative: Restores function or appearance to traumatized or malfunctioning
tissues, for example internal fixation of fractures and scar revision.
Constructive Restores function lost or reduced as result of congenital anomalies. This include
repair of cleft palate, closure of atrial septal defect in heart.
Cosmetic: It is performed to improve personal appearance Blepharoplasty for eyelid deformities;
rhinoplasty to reshape nose.
Preoperative Surgical Phase
Patients having surgery enter the health care setting in different stages of health. A patient may
enter the hospital or ambulatory surgical centre on a predetermined day feeling relatively healthy
and prepared to face elective surgery. In contrast, a person in a motor vehicle crash may face
emergency surgery with no time to prepare. The ability to establish rapport and maintain a
professional relationship with the patient is an essential component of the preoperative phase.
The patient meets many health care personnel, including surgeons, nurse anaesthetists,
anaesthesiologists, surgical technologists, and nurses. All play a role in the patient’s care and
recovery. Family members attempt to provide support through their presence but face many of
the same stressors as the patient.
Assessment
A thorough patient assessment and critical analysis of findings ensure that you make patient-
centred clinical decisions required for safe nursing care. The aim of the preoperative assessment
is to identify the patient’s normal preoperative function to recognize, prevent, and minimize
possible postoperative complications. A multidisciplinary team approach is essential. Patients are
admitted only hours before surgery; thus it is important for nurse to organize and verify data
obtained before surgery and implement a perioperative plan of care. Most assessments begin
before admission for surgery; in the health care provider’s office, preadmission clinic, or
anaesthesia clinic or by telephone. A health care provider performs a physical examination or
orders laboratory tests and before surgery nurses begin teaching, answer questions, and begin
paperwork. This streamlines the care required by the patient on the day of surgery. So as not to
waste time duplicating information from the preoperative examination, focus on key
measurements for all body systems to ensure that no one overlooked any obvious problems.
Even though the surgeon screens the patient before scheduling surgery, preoperative assessment
occasionally reveals an abnormality that delays or cancels surgery. For example, consider an
infection in a patient with a cough and low-grade fever on admission and notify the surgeon
immediately.
Nursing History: An initial interview is conducted to collect a patient history. If a patient is
unable to relate all of the necessary information, family members can be relied on as resources.
Medical History: A review of the patient’s medical history includes past illnesses and surgeries
and the primary reason for seeking medical care. The patient’s current medical record and
medical records from past hospitalisations are excellent sources of data. Pre-existing illnesses
influence patients’ abilities to tolerate surgery and nurses’ choices of therapies to help them
reach full recovery. The history of previous surgery influences the level of physical care required

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after an upcoming surgical procedure. Screen patients scheduled for ambulatory surgery for
medical conditions that increase the risk for complications during or after surgery. For example,
a patient who has a history of heart failure may experience a further decline in cardiac function
during and after surgery. The patient with heart failure in the preoperative period may require
beta-blocker medications, intravenous (IV) fluids infused at a slower rate, or administration of a
diuretic after blood transfusions.
Medication History: Presence of pre-existing co-morbid conditions such as hypertension, renal
or heart disease, respiratory disorders, and diabetes increases a patient’s surgical risk. If a patient
regularly uses prescription or over-the-counter medications, the surgeon or anaesthesia provider
may temporarily discontinue the drugs before surgery or adjust the dosages. Certain medications
pose greater risks for surgical complications.
Allergies: Assess for patients’ allergies to drugs during the perioperative period. Also assess for
latex, food, and contact allergies (e.g., to tape, ointments, or solutions). Allergies are not the
same as unpleasant side effects. For example, codeine may cause nausea (a side effect) or
hypotension and confusion (an allergy). When asking a patient about allergies, realize that the
term allergy is confusing for some patients. Asking a patient if he or she has ever “had a problem
with a medication or substance” is a helpful approach to questioning.
Smoking Habits: The patient who smokes is at greater risk for postoperative pulmonary
complications than a patient who does not. The chronic smoker already has an increased amount
and thickness of mucus secretions in the lungs. General anaesthetics increase airway irritation
and stimulate pulmonary secretions, which the airways retain as a result of reduction in ciliary
activity during anaesthesia. After surgery the patient who smokes has greater difficulty clearing
the airways of mucus secretions and needs to know the importance of postoperative deep
breathing and coughing.
Alcohol Ingestion and Substance Use and Abuse: Habitual use of alcohol and illegal drugs
predisposes the patient to adverse reactions to anaesthetic agents. Some patients experience a
cross-tolerance to anaesthetic agents, necessitating higher-than normal doses.
Occupation: Surgery often results in physical changes and limits that prevent a person from
returning to work or lengthen recovery time before work can be resumed. Assess the patient’s
occupational history to anticipate the possible effects of surgery on recovery, return to work, and
eventual work performance. Explain any restrictions such as lifting, use of the extremities, or
climbing stairs before a patient returns to work. When a patient is unable to return to a job, refer
him or her to a social worker and/or occupational therapist for job-training programs or to help
him or her seek economic assistance.
Preoperative Pain Assessment: Surgical manipulation of tissues, treatments, and positioning on
the operation table contribute to postoperative pain. There is a need to conduct a comprehensive
pain assessment, including the patient’s and family’s expectations for pain management
following surgery. Ask patients to describe their perceived tolerance to pain, past experiences,
and prior successful interventions used.

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Review of Emotional Health: Surgery is psychologically stressful. Patients are often anxious
about the surgery and its implications and believe that they are powerless over their situation.
Family members may perceive the patient’s surgery as a disruption of their lifestyle.
Hospitalization and the recovery period at home are sometimes lengthy. The family is usually
concerned about the patient returning to a normal, productive life. When the patient has chronic
illness, the family is either fearful that surgery will result in further disability or hopeful that it
will improve their lifestyle. To understand the impact of surgery on a patient’s and family’s
emotional health, assess the patient’s feelings about surgery, self-concept, body image, and
coping resources.
Self-Concept: Patients with a positive self-concept are more likely to approach surgical
experiences appropriately. Poor self-concept hinders the ability to adapt to the stress of surgery
and aggravates feelings of guilt or inadequacy.
Body Image: Surgical removal of any diseased body part often leaves permanent disfigurement,
alteration in body function, or concern over mutilation. Loss of certain body functions (e.g., with
a colostomy or amputation) may compound a patient’s fears. Assess for body image alterations
that patients perceive will result from surgery. Often surgery changes the physical or
psychological aspects of patients’ sexuality. Surgery such as hernia repair or cataract extraction
forces patients to temporarily refrain from sexual intercourse until they return to normal physical
activity. Encourage patients to express concerns about their sexuality. Hold discussions about the
patient’s sexuality with his or her sexual partner so the partner gains a shared understanding of
how to cope with limitations in sexual function.
Coping Resources: Assessment of feelings and self-concept reveals whether the patient is able to
cope with the stress of surgery. The physiological effects of stress are well documented. When
reviewing the patient’s coping resources, ask him or her about specific family members and
friends who may provide support. Once identified, include these individuals in any patient
teaching and interventions to manage stress and anxiety.
Physical Examination: Conduct a partial or complete physical examination, depending on the
amount of time available and the patient’s preoperative condition.
General Survey: Observe the patient’s general appearance. Gestures and body movements may
reflect weakness caused by illness. Assess the patient for a malnourished appearance. Height,
body weight, and history of recent weight loss are important indicators of nutritional status.
Preoperative vital signs, including blood pressure while sitting and standing, and pulse oximetry
provide important baseline data with which to compare alterations that occur during and after
surgery. An elevated temperature before surgery is a cause for concern. If the patient has an
underlying infection, the surgeon may choose to postpone surgery until the infection has been
treated.
Head and Neck: The condition of oral mucous membranes is one indicator of the level of
hydration. Inspect the area between the gums and cheek, the soft palate, and the nasal sinuses.
Sinus drainage indicates respiratory or sinus infection. During the examination of the oral

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mucosa, identify any loose or capped teeth because they can become dislodged during
endotracheal intubation.
Integument: Carefully inspect the skin, especially over bony prominences such as the heels,
elbows, sacrum, back of head, and scapula. During surgery patients often lie in a fixed position
for several hours, making them at increased risk for pressure ulcers.
Thorax and Lungs: Assessment of the patient’s breathing pattern and chest excursion measures
ventilatory capacity. A decline in ventilatory function places the patient at risk for respiratory
complications.
Heart and Vascular System: Assess the character of the apical pulse and listen to heart sounds.
Assess peripheral pulses, capillary refill, and the colour and temperature of extremities.
Abdomen: Assess the abdomen for size, shape, symmetry, and presence of distention. Ask how
often the patient has regular bowel movements and inquire about the colour and consistency of
stools. Auscultate bowel sounds.
Neurological Status: Preoperative assessment of neurological status is important for all patients
receiving general anaesthesia. The baseline neurological status assists with the assessment of
ascent from anaesthesia. Observe the patient’s level of orientation, alertness, mood, and ease of
speech, noting whether he or she answers questions appropriately and is able to recall recent and
past events.
Diagnostic Screening: Patients have a variety of preoperative tests and procedures to confirm or
rule out pre-existing alterations requiring surgery or that will affect recovery. The patient’s
medical history, physical assessment findings, and surgical procedure determine the type of tests
ordered. For example, a type and cross-match are indicated before surgery for procedures in
which blood loss is expected.
Preoperative Teaching Plan: Successful planning requires involving the surgical patient and
family to set realistic expectations for care. Early involvement of the patient when developing
the surgical care plan minimizes surgical risks and postoperative complications. A patient
informed about the surgical experience is less likely to be fearful and is able to participate in the
postoperative recovery phase so expected outcomes are met.
Informed Consent: Surgery cannot be legally or ethically performed until a patient understands
the need for a procedure, the steps involved, risks, expected results, and alternative treatments.
It is the surgeon’s responsibility to explain the procedure and obtain the informed consent. After
the patient completes the consent form, place it in the medical record.
Preoperative Teaching: Patient education is an important aspect of the patient’s surgical
experience. Provided in a systematic and structured format with teaching and learning principles,
preoperative teaching regarding a patient’s expected postoperative course has a positive
influence on the patient’s recovery. It is ideal to attempt perioperative education before
admission, during the hospital stay, and after discharge. Including family members in
perioperative preparation is advisable. Often a family member is the coach for postoperative
exercises when the patient returns from surgery. The family often has better retention of
preoperative teaching and will be with the patient and able to help them in their recovery. If

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anxious relatives do not understand routine postoperative events, it is likely that their anxiety
heightens the patient’s fears and concerns.
Physical Preparation: The degree of preoperative physical preparation depends on the patient’s
health status, the planned surgery, and the surgeon’s preferences. A seriously ill patient receives
more supportive care in the form of medications, IV fluid therapy, and monitoring than the
patient facing a minor elective procedure.
Maintaining Normal Fluid and Electrolyte Balance: The surgical patient is vulnerable to fluid
and electrolyte imbalances as a result of the stress of surgery, inadequate preoperative intake, and
the potential for excessive fluid losses during surgery.
Preoperative Fasting: There is a need to observe preoperative fasting for elective procedures
requiring general anaesthesia, regional anaesthesia, or sedation. For non-emergent procedures,
clients should not take clear liquids for 2 hours; do not take breast milk for 4 hours; and do not
take formula, solids, and nonhuman milk for 6 hours. For fatty, fried, and meat sources the
recommended fast is for 8 hours.
Preventing Bowel and Bladder Incontinence: Some patients receive a bowel preparation (e.g.,
a cathartic or enema) if the surgery involves the lower GI system or lower abdominal organs.
Manipulation of portions of the GI tract during surgery results in absence of peristalsis for 24
hours and sometimes longer. Enemas and cathartics such as polyethylene glycol electrolyte
solution (GoLytely) clean the GI tract to prevent intraoperative incontinence and postoperative
constipation. An empty bowel reduces risk of injury to the intestines and minimizes
contamination of the operative wound if a portion of the bowel is incised or opened accidentally
or if colon surgery is planned.
Hygiene: Basic hygiene measures provide additional comfort before surgery. If the hospitalized
patient is unwilling to take a complete bath, a partial bath is refreshing and removes irritating
secretions or drainage from the skin. Because the patient cannot wear personal nightwear to the
operating room because it is restrictive and is a flammable hazard, provide a clean hospital
gown. When the patient is NPO for the last several hours, his or her mouth is often very dry.
Offer the patient mouthwash and toothpaste, again cautioning the patient not to swallow water.
Hair and Cosmetics: During surgery with the patient under general anaesthesia, his or her head
is positioned to introduce an endotracheal tube into the airway. This procedure may involve
manipulation of the patient’s hair and scalp. To avoid injury ask the patient to remove hairpins or
clips before leaving for surgery. Electrocautery is frequently used during surgery. Hairpins and
clips can become an exit source for the electricity and cause burns. Remove hairpieces or wigs as
well. The patient applies a disposable hat before entering the OR. During and after surgery the
anaesthesia provider and nurse assess skin and mucous membranes to determine the patient’s
level of oxygenation and circulation. Therefore remove all makeup (i.e., lipstick, powder, blush,
nail polish) to expose normal skin and nail colouring. Pulse oximetry records accurate
measurements through
Removal of Prostheses: It is easy for any type of prosthetic device to become lost or damaged
during surgery. The patient needs to remove all prostheses, including partial or complete

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dentures, artificial limbs, artificial eyes, and hearing aids. If a patient has a brace or splint, check
with the health care provider to determine whether it should remain with him or her.
For many patients it is embarrassing to remove dentures, wigs, or other devices that enhance
personal appearance. Always offer privacy as the patient removes personal items. Patients are
sometimes allowed to keep these until they reach the preoperative area. Place dentures in special
containers, labelled with the patient’s name and other identification required by the agency, for
safekeeping to prevent loss or breakage. In many agencies you document an inventory of all
prosthetic devices or personal items and have them locked away. It is also common practice for
nurses to give prostheses to family members or to keep the devices at the patient’s bedside.
Document these actions in the nursing notes, surgical checklist, or per agency policy.
Vital Signs: Measure a final preoperative set of vital signs. The anaesthesia provider uses these
values as a baseline for intraoperative vital signs. If preoperative vital signs are abnormal,
surgery may need to be postponed. Notify the surgeon of any abnormalities before sending the
patient to surgery.
Documentation: Before the patient goes to the OR, check the contents of the medical record to
be sure that pertinent laboratory results are present. Check consent forms for accuracy. A
preoperative checklist is a useful tool for ensuring patient safety and completing nursing
interventions. Check the nurses’ notes to be sure that documentation of care is current. This is
especially important if the hospitalized patient experienced unpredicted problems the night
before surgery. Send a current medication administration record to the operating room.
Other Procedures: If an IV infusion is not started on the hospital unit, one will be placed in the
preoperative holding area. An IV line is essential for establishing a route to deliver medications
and fluids during surgery. Some patients need a nasogastric (NG) tube inserted before surgery,
but this often occurs in the OR
Administering Preoperative Medications: The anaesthesia provider or surgeon sometimes
orders pre-anaesthetic drugs to reduce the patient’s anxiety, the amount of general anaesthesia
required, the risk of nausea and vomiting and resultant aspiration, and respiratory tract
secretions.
Eliminating Wrong Site and Wrong Procedure Surgery:
Because of errors made in the past with patients undergoing the wrong surgery or having surgery
performed on the wrong site, there is a Universal Protocol guidelines for preventing such
mishaps. The three principles of the protocol include the following: (1) a preoperative
verification that ensures that all relevant documents (e.g., consent forms, allergies, medical
history, physical assessment findings) and results of laboratory tests and diagnostic studies are
available before the start of the procedure and that the type of surgery scheduled is consistent
with the patient’s expectations; (2) marking the operative site with indelible ink to mark left and
right distinction, multiple structures (e.g., fingers), and levels of the spine; and (3) a “time out”
just before starting the procedure for final verification of the correct patient, procedure, site, and
any implants. All members of the surgical/procedure team perform the time out. This protocol

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includes active patient or a legally designated representative involvement in the entire process. If
the patient refuses a mark, note this on the procedure checklist and notify the surgeon.
Nursing Diagnosis
Preoperative nursing diagnoses allow you to take precautions and actions so care provided
during the intraoperative and postoperative phases is consistent with the patient’s needs. Nursing
diagnoses made before surgery also focus on the potential risks that a patient may face after
surgery. Preventive care is essential so you can manage the surgical patient effectively. The
following are some common nursing diagnoses relevant to the patient having surgery:
Ineffective airway clearance, anxiety, fear, risk for deficient fluid volume, risk for perioperative
positioning injury, impaired physical mobility, nausea, acute pain and delayed surgical recovery.
Transport to the Operating Room
Personnel in the OR notify the nursing unit or ambulatory surgery area when it is time for
surgery. In many hospitals a nursing orderly or transporter brings a stretcher for transporting the
patient. The transporter checks the patient’s identification bracelet for two identifiers (name,
birth date, or hospital number) against the patient’s medical record to be sure that the right
person is going to surgery. Because some patients receive preoperative sedatives, the nurses and
transporter help the patient transfer from bed to stretcher to prevent falls. The ambulatory
surgery patient ambulates to the OR if able and not medicated. Provide the family an opportunity
to visit before the patient is transported to the OR. Direct the family to a waiting area. In some
hospitals the family is allowed to wait with the patient in the OR holding area until he or she is
transported into the OR.
Intraoperative Surgical Phase
Care of the patient during surgery requires careful preparation and knowledge of the events that
occur during the surgical procedure. The nurse usually functions in one of two roles: circulating
nurse or scrub nurse. The circulating nurse must be an RN. His or her responsibilities include
reviewing the preoperative assessment, establishing and implementing the intraoperative plan of
care, evaluating the care, and providing for continuity of care after surgery. The circulating nurse
assists with procedures such as endotracheal intubation and blood administration as needed. In
addition, this nurse positions the patient, monitors sterile technique and a safe OR environment,
assists the surgeon and surgical team by operating nonsterile equipment, provides additional
supplies, verifies sponge and instrument counts, and maintains accurate and complete written
records.
The scrub nurse is an RN. This individual maintains a sterile field during the surgical
procedure, assists with applying sterile drapes, hands instruments and other sterile supplies to
surgeons and counts the sponges and instruments.
Preoperative (Holding) Area
In most hospitals the patient enters a holding area, also known as the pre-anaesthesia care unit or
pre-surgical care unit (PSCU), outside the OR. In the PSCU the nurse explains the steps for
preparing the patient for surgery, reviews the preoperative checklist, assesses the patient’s
readiness both physically and emotionally, and reinforces teaching. Nurses in the PSCU are

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members of the OR staff and wear surgical scrub suits, hats, and footwear in accordance with
infection control policies. In the PSCU the nurse or anaesthesia provider inserts an IV catheter
into the arm to establish a route for fluid replacement and IV drugs if not placed previously. A
large-bore (18-gauge) IV catheter ensures easy infusion of fluids and blood products if
necessary. The nurse monitors vital signs, including pulse oximetry. The anaesthesia provider
usually performs a patient assessment at this time. Because of the preoperative medications, the
patient begins to feel drowsy. The temperature in the PSCU and adjacent OR suites is usually
cool. Offer the patient an extra blanket. Conscious sedation starts at this time. The patient’s stay
in the PSCU is usually brief.
Admission to the Operating Room
The OR staff transfer the patient to the OR room via a stretcher. The patient is usually still awake
and notices nurses and health care providers wearing complete surgical masks, gowns, and
eyewear. The staff carefully transfer the patient to the OR table, being sure that the stretcher and
table are locked in place. After the patient is on the table, fasten a safety strap around him or her.
Support the patient by explaining procedures and encouraging him or her to ask questions. Sights
and sounds in the surgical suite are sometimes frightening to patients.
Physical Preparation: After safely securing the patient on the OR table, apply monitoring
devices to him or her. Patients receiving general and regional anaesthesia undergo continuous
electrocardiogram (ECG) and pulse oximetry monitoring. For ECG, place electrodes on the chest
and extremities to record electrical activity of the heart. A monitor in the OR displays this
activity. Pulse oximetry monitors oxygen saturation. Apply an electrical cautery grounding pad
to the skin so cauterizing instruments can be used safely. Apply graded compression stockings
(e.g., elastic stockings). Document compression device application, capillary refill, and patient
tolerance to procedures. For limb surgeries assess peripheral pulses distal to the operative site.
Measure temperature continuously via bladder, oesophageal, or rectal probes.
Latex Sensitivity/Allergy: As the incidence and prevalence of latex sensitivity and allergy
increase, the need for recognition of potential sources of latex is extremely critical.
The OR and post-anaesthesia care unit (PACU) have many products that contain latex (e.g.,
gloves, IV tubing, syringes, and rubber stoppers on bottles and vials). It is also present in
common objects such as adhesive tape, disposable electrodes, endotracheal tube cuffs, protective
sheets, and ventilator equipment. Signs and symptoms of a latex reaction include local effects
ranging from urticaria and flat or raised red patches to vesicular, scaling, or bleeding eruptions.
Acute dermatitis is sometimes present. Rhinitis and/or rhinorrhea are other common reactions to
mild and severe latex allergy. Immediate hypersensitivity reactions are life threatening, with the
patient exhibiting focal or generalized urticaria and oedema, bronchospasm, and mucus
hypersecretion, all of which can compromise respiratory status.
Introduction of Anaesthesia: Patients undergoing surgical procedures receive one of four types
of anaesthesia: general, regional, local, or conscious sedation.
a. General Anaesthesia (GA): Modern anaesthetic agents are much easier to reverse and allow
the patient to recover with fewer negative effects. General anaesthesia results in an immobile,

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quiet patient who does not recall the surgical procedure. The patient’s amnesia acts as a
protective measure from the unpleasant events of the procedure. An anaesthesia provider
gives general anaesthetics by IV infusion and inhalation routes through the three phases of
anaesthesia: induction, maintenance, and emergence. Surgery requiring general anaesthesia
involves major procedures with extensive tissue manipulation. Induction includes the
administration of anaesthetic agents and endotracheal intubation. The maintenance phase
includes positioning the patient, preparing the skin for incision, and the surgical procedure
itself. Appropriate levels of anaesthesia are maintained during this phase. During emergence
anaesthetics are decreased, and the patient begins to awaken. Because of the short half-life of
today’s medications, emergence often occurs in the OR. The duration of anaesthesia depends
on the length of surgery. The greatest risks from general anaesthesia are the side effects of
anaesthetic agents, including cardiovascular depression or irritability, respiratory depression,
and liver and kidney damage.
b. Regional Anaesthesia. Induction of regional anaesthesia results in loss of sensation in an
area of the body. The method of induction such as spinal, epidural, or a peripheral nerve
block influences the portion of sensory pathways that are anesthetised. No loss of
consciousness occurs with regional anaesthesia, but the patient is often sedated. The
anaesthesia provider gives regional anaesthetics by infiltration and local application. It is
necessary to frequently observe the position of extremities and the condition of the skin.
c. Local Anaesthesia. It involves loss of sensation at the desired site (e.g., a skin growth or the
cornea of the eye). The anaesthetic agent (e.g., lidocaine [Xylocaine]) inhibits nerve
conduction until the drug diffuses into the circulation. It is injected locally or applied
topically. The patient experiences a loss in pain and touch sensation and motor and
autonomic activities (e.g., bladder emptying). Local anaesthesia is common for minor
procedures performed in ambulatory surgery.
d. Conscious Sedation. It is routinely used for procedures that do not require complete
anaesthesia but rather a depressed level of consciousness. A patient under conscious sedation
must independently maintain a patent airway and adequate ventilation and be able to respond
appropriately to verbal stimuli or light tactile stimulation. Short-acting IV sedatives such as
midazolam (Versed) are given. Advantages of conscious sedation include adequate sedation,
reduction of fear and anxiety, amnesia, relief of pain and noxious stimuli, mood alteration,
elevation of pain threshold, enhanced patient cooperation, stable vital signs, and rapid
recovery. A variety of therapeutic procedures is appropriate for conscious sedation.
Nurses assisting with the administration of local anaesthesia and conscious sedation need to
demonstrate competency in the care of these patients. Knowledge of anatomy, physiology,
cardiac dysrhythmias, procedural complications, and pharmacological principles related to the
administration of individual agents is essential. You also need to assess, diagnose, and intervene
in the event of untoward reactions and demonstrate skill in airway management and oxygen
delivery

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Positioning the Patient for Surgery; During general anaesthesia the nursing personnel and
surgeon often do not position the patient until the stage of complete relaxation. The surgical
approach usually determines the choice of position. Ideally the patient’s position provides good
access to the operative site, sustains adequate circulatory and respiratory function, and ensures
the patient’s safety and skin integrity. It should not impair neuromuscular structures. An alert
person maintains normal range of joint motion by pain and pressure receptors. If a joint is
extended too far, pain stimuli provide a warning that muscle and joint strain is too great. In a
patient who is anaesthetised, normal defence mechanisms cannot guard against joint damage,
muscle stretch, and strain. The muscles are so relaxed that it is relatively easy to place the patient
in a position the individual normally could not assume while awake. He or she often remains in a
given position for several hours. Although it may be necessary to place a patient in an unusual
position, try to maintain correct alignment and protect him or her from pressure, abrasion, and
other injuries. Positioning should not impede normal movement of the diaphragm or interfere
with circulation to body parts. If restraints are necessary, pad the skin to prevent trauma.
Documentation of Intraoperative Care: Throughout the surgical procedure, keep an accurate
record of patient care activities and procedures performed by OR personnel. Documentation of
intraoperative care provides useful data for the patient’s postoperative period.
Nursing Diagnosis
Review preoperative nursing diagnoses and modify them to individualize the care plan in the
OR. The following are some common nursing diagnoses relevant to the patient intraoperatively:
Ineffective airway clearance, risk for deficient fluid volume, risk for perioperative positioning
injury and risk for impaired skin integrity.
Postoperative Surgical Phase
After surgery a patient’s care is often complex as a result of physiological changes. The type of
anaesthesia, nature of surgery, and the patient’s previous condition determine the phases of
recovery that he or she undergoes and the length of time spent in convalescence on an acute care
nursing unit. Typically at the end of surgery the anaesthesia provider and the circulating nurse
accompany the patient to the PACU and provide a report to the nursing staff. Patients who
undergo general anaesthesia are more likely to face complications than those who have only
local anaesthesia or conscious sedation.
Before the patient arrives in the PACU, a PACU nurse obtains data from the surgical team in the
OR regarding the patient’s general status and need for special equipment and nursing care.
Careful planning allows the nursing staff to consider placement of patients in the PACU. Use
standard precautions for infection control for all patients. When the patient is admitted to phase I
recovery, personnel notify the nurses on the acute care nursing unit of his or her arrival.
This allows the nursing staff to inform family members. Family members usually remain in the
designated waiting area so they can be found when the surgeon arrives to explain the patient’s
condition. It is the surgeon’s responsibility to describe the patient’s status, the results of surgery,
and any complications that occurred.

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A standardized approach or tool for “hand-off” communications assists in providing accurate
information about a patient’s care, treatment and services, current condition, and any recent or
anticipated changes. The surgical team’s report includes a review of anaesthetic agents
administered so the PACU nurse is able to anticipate how quickly a patient should regain
consciousness and analgesic needs. The OR nurse or anaesthesia provider discusses whether
there were complications during surgery such as excessive blood loss or cardiac irregularities.
He or she also reports intraoperative patient positioning and condition of the skin. Frequently this
report takes place while PACU nurses are admitting the patient. The PACU nurse attaches the
patient to monitoring equipment such as the non-invasive blood pressure monitor, ECG monitor,
and pulse oximeter. Patients often receive some form of oxygen in this immediate recovery
period. After receiving hand-off communication from the OR, the PACU nurse conducts a
complete systems assessment during the first few minutes of PACU care. Assessments are
performed at least every 15 minutes or more frequently, depending on the patient’s condition and
unit policy. This assessment usually continues until discharge from the PACU. In the PACU,
nursing interventions focus on monitoring and maintaining airway, respiratory, circulatory, and
neurological status and managing pain. When the patient is stable, the OR staff transport the
patient on a stretcher to the nursing unit. Staff members from the unit assist in safely transferring
the patient to a bed.
Maintaining Respiratory Function: To prevent respiratory complications begin pulmonary
interventions early. The benefits of thorough preoperative teaching are reached when patients are
able to participate actively in postoperative exercises. When patients awaken from anaesthesia,
help them maintain a patent airway. Position the patient on one side with the face downward and
the neck slightly extended to facilitate a forward movement of the tongue and the flow of mucus
secretions out of the mouth. Suction artificial airways and the oral cavity for mucus secretions.
Before you remove an artificial airway (or the patient removes it), suction the back of the airway
so secretions are not retained.
Achieving Rest and Comfort: Pain control is a priority to facilitate a surgical patient’s
recovery. A patient’s pain increases following surgery as the effects of anaesthesia diminish. The
patient becomes more aware of the surroundings and more perceptive of discomfort. The
incisional area is only one source of pain. Irritation from drainage tubes, tight dressings, or casts
and the muscular strains caused from positioning on the OR table also cause discomfort.
It is common to administer opioid analgesics (e.g., morphine or fentanyl) immediately after
surgery. Initial analgesic doses are usually given by IV infusion in the PACU and titrated to
patient comfort.
Temperature Regulation: Temperature regulation is important after surgery. Patients are often
cool after surgery; the PACU nurse provides warmed blankets immediately. If the temperature is
35.6° C (96° F) or below, use forced air or a convective warming device. Increasing body
warmth causes the patient’s metabolism to rise and circulatory and respiratory functions to
improve. Shivering is not always a sign of hypothermia but rather a side effect of certain

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anaesthetic agents. Deep breathing and coughing are performed to help to expel retained
anaesthetic gases.
Malignant hyperthermia is a potentially lethal condition that can occur in patients receiving
various inhaled anaesthetic agents and succinylcholine. Suspect this when there is unexpected
tachycardia and tarchypnoea; elevated carbon dioxide levels; jaw muscle rigidity; body rigidity
of limbs, abdomen, and chest; or hyperkalaemia. Surgical patients are at risk for infection for
various reasons. If a patient becomes febrile, be aggressive in providing routine postoperative
nursing interventions. For example, deep breathing and coughing, early ambulation, prompt
removal of indwelling urinary and IV catheters, and aseptic care of the surgical wound decrease
the risk of postoperative infections. Obtain wound and or blood cultures from patients suspected
of having infections.
Maintaining Neurological Function: Orientation to the environment is important in
maintaining the patient’s mental status. Reorient the patient, explain that surgery is completed,
and describe procedures and nursing measures. The patient who was properly prepared before
surgery is less likely to be anxious during the postoperative period. Report any change in level of
consciousness to health care providers.
Maintaining Fluid and Electrolyte Balance: An important nursing responsibility is
maintaining patency of IV infusions in the postoperative period. The patient’s only source of
fluid intake immediately after surgery is through IV catheters. The health care provider orders a
prescribed rate for each infusion. As the patient begins to take and tolerate oral fluids, the IV rate
is decreased. When an ambulatory surgical patient awakens and is able to tolerate fluids by
mouth without GI upset, the health care provider orders removal of the IV catheter.
Promoting Normal Bowel Elimination and Adequate Nutrition: Normally a patient who has
had general anaesthesia does not receive fluids to drink in the PACU because of bowel
sluggishness, the risk of nausea and vomiting, and grogginess from general anaesthesia. To
minimize nausea, avoid suddenly moving the patient. For patients at high risk for the
development of nausea and vomiting or those who must not vomit (e.g., eye surgery), a
combination of anti-emetics is often more effective than a single agent. If the patient has an NG
tube, keep it patent by irrigating it. Occlusion of an NG tube results in accumulation of gastric
contents within the stomach. Patients who have had abdominal surgery are usually NPO the first
24 to 48 hours. As flatus and peristalsis return, provide clear liquids, followed by full liquids, a
light diet of solid foods, and finally a patient’s usual diet. Encourage intake of foods high in
protein and vitamin C.
Promoting Urinary Elimination: The depressant effects of anaesthetics and analgesics impair
the sensation of bladder fullness. If bladder tone is reduced, the patient has difficulty starting
urination. However, patients need to void within 8 to 12 hours after surgery. Because a full
bladder is painful and often causes restlessness in recovery, it often becomes necessary to insert a
straight catheter. If the patient has an indwelling urinary catheter, the goal is to remove it as soon
as possible. Monitor I&O. If a patient has an indwelling catheter, expect an output of about 30 to

15. 15
50 mL/hr. An accepted level of urinary output is at least 1 mL/kg/hr for adults. For example, a
132-pound woman (60 kg) would be expected to produce 60 mL of urine hourly.
Promoting Wound Healing: A surgical wound undergoes considerable stress during
convalescence. The stresses of inadequate nutrition, impaired circulation, and metabolic
alterations increase the risk for delayed healing. A clean surgical wound usually does not regain
strength against normal stress for 15 to 20 days after surgery. Use aseptic technique during
dressing changes and wound care. Keep surgical drains patent so accumulated secretions can
escape from the wound bed. Ongoing observation of the wound identifies early signs and
symptoms of infection.
Nursing Diagnosis
The following are some of post-operative nursing diagnoses; ineffective airway clearance,
anxiety, fear, risk for infection, deficient knowledge, impaired physical mobility, nausea, acute
pain ad delayed surgical recovery.
Postoperative Complications
Respiratory System
Atelectasis: Collapse of alveoli with retained mucus secretions. Anaesthesia, analgesia, and
immobilized position prevent full lung expansion.
Pneumonia: It occurs as a result of poor lung expansion with retained secretions or aspirated
secretions.
Pulmonary embolism: Embolus blocking pulmonary arterial blood flow to one or more lobes of
lung. Signs and symptoms include dyspnoea, sudden chest pain, cyanosis, tachycardia, and drop
in blood pressure. Same factors lead to formation of thrombus or embolus. Immobilized surgical
patient with pre-existing circulatory or coagulation disorders is at risk.
Circulatory System
Haemorrhage.
Hypovolemic shock
Thrombophlebitis: Inflammation of vein often accompanied by clot formation. Veins in legs are
most commonly affected. Signs and symptoms include swelling and inflammation of involved
site and aching or cramping pain. Vein feels hard, cordlike, and sensitive to touch. Prolonged
sitting or immobilization aggravates venous stasis. Trauma to vessel wall and hypercoagulability
of blood increase risk of vessel inflammation.
Thrombus: Formation of clot attached to interior wall of a vein or artery, which can occlude the
vessel lumen. Symptoms include localized tenderness along distribution of the venous system,
swollen calf or thigh, calf swelling >3 cm (1.2 in) compared to asymptomatic leg, pitting oedema
in symptomatic leg, and decrease in pulse below location of thrombus (if arterial).
Embolus: Piece of thrombus that has dislodged and circulates in bloodstream until it lodges in
another vessel (commonly lungs, heart, brain, or mesentery).
Gastrointestinal System
Paralytic ileus: Non-mechanical obstruction of the bowel caused by physiological, neurogenic,
or chemical imbalance associated with decreased peristalsis. It is common in initial hours after

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abdominal surgery. Handling of intestines during surgery leads to loss of peristalsis for a few
hours to several days.
Abdominal distention: Retention of air within intestines and abdominal cavity during
gastrointestinal surgery. Signs and symptoms include increased abdominal girth, patient
complaints of fullness, and “gas pains.” Slowed peristalsis from anaesthesia, bowel
manipulation, or immobilization.
Nausea and vomiting
Genitourinary System
Urinary retention: Involuntary accumulation of urine in bladder as result of loss of muscle tone.
Signs and symptoms include inability to void, restlessness, and bladder distention. It appears 6-8
hours after surgery.
Urinary tract infection: Signs and symptoms include dysuria, itching, abdominal pain, possible
fever, cloudy urine, presence of WBCs and leukocyte esterase positive on urinalysis. It is most
frequently a result of catheterization of the bladder.
Integumentary System
Wound infection: An invasion of deep or superficial wound tissues by pathogenic
microorganisms; signs and symptoms include warm, red, and tender skin around incision; fever
and chills; purulent material exiting from drains or from separated wound edges. Infection
usually appears 3-6 days after surgery. Infection is caused by poor aseptic technique or
contaminated wound or surgical site before surgical exploration
Wound dehiscence: Separation of wound edges at suture line. Signs and symptoms include
increased drainage and appearance of underlying tissues. This usually occurs 6-8 days after
surgery. Malnutrition, obesity, preoperative radiation to surgical site, old age, unusual strain on
suture line from coughing or positioning and poor circulation to tissues are causes of dehiscence.
Wound evisceration: Protrusion of internal organs and tissues through incision. Incidence usually
occurs 6-8 days after surgery. Patient with dehiscence is at risk for developing evisceration.
Skin breakdown: Result of pressure or shearing forces. Surgical patients are at increased risk if
alterations in nutrition and circulation are present, resulting in oedema and delayed healing.
Prolonged periods on the OR table and in the bed after surgery lead to pressure breakdown. Skin
breakdown results from shearing during positioning on the OR table and improperly pulling
patient up in bed.
Nervous System
Intractable pain: Pain that is not amenable to analgesics and pain-alleviating interventions.
Intractable pain may be related to the wound or dressing, anxiety, or positioning.
Malignant hyperthermia: Severe hypermetabolic state and rigidity of the skeletal muscles caused
by an increase in intracellular calcium ion concentration. Rare genetic condition triggered with
exposure to inhaled anaesthetic agents and the depolarizing muscle relaxant succinylcholine.